Stings, Bites, and Pediculosis 2024 PDF

Summary

This document provides information about stings, bites, and pediculosis, encompassing various aspects including causes, symptoms, and treatment. The document includes details on different types of insects and their effects, from mosquitoes and fleas to bed bugs and ticks, and relevant prevention and treatment approaches.

Full Transcript

STINGS, BITES, & PEDICULOSIS Chapters 37 Kelly Orr, PharmD, Clinical Professor Insect Bites Mosquitoes Anticoagulant saliva causes swelling and itching Vectors for EEE, West Nile, Chikungunya, and Zika viruses Fleas Usually multiple, gro...

STINGS, BITES, & PEDICULOSIS Chapters 37 Kelly Orr, PharmD, Clinical Professor Insect Bites Mosquitoes Anticoagulant saliva causes swelling and itching Vectors for EEE, West Nile, Chikungunya, and Zika viruses Fleas Usually multiple, grouped, primarily on legs and ankles Red swelling around puncture, intense itching Can transmit bubonic plague & endemic typhus Scabies Sacroptes scabiei, tiny arachnid mite burrows up to 1 cm into stratum corneum and females deposit eggs in “tunnels” Presents at interdigital spaces of fingers, flexor surfaces of wrists, external male genitalia, buttocks, anterior axillary folds Inflammation and intense itching, may be transmitted from person to person Insect Bites - Continued Bed bugs Hide and deposit eggs in crevices, such as bedding, folds in linen, suitcases, picture frames – Come out and bite at night Increased global travel and resistance to pesticides has increased incidence Presents with bites to head, neck, and arms in clusters of 2 – 3 in a straight line Ticks Lyme disease, Rocky Mountain Spotted Fever, Ehrlichiosis If tick removed but mouth parts left behind may cause itching and nodules to develop Remove intact, within 36 hours, with fine tweezers Insect Bites - Continued Chiggers Live in shrubs, trees, and grass Larvae secrete digestive enzyme to cause cell destruction, intense itching/red papule Skin hardens and makes a tube for it to feed, engorge, and fall off Spiders All species venomous, most cannot penetrate skin with fangs (except: black widow, recluse, & hobo) Black widow bite – delayed pain, stiffness, joint pain, fever, chills, abdominal discomfort Brown recluse = spreading ulcerated wound; Hobo = mod-severe slow healing wound Treatment Goals & General Approach for Insect Bites ◦ Goals are to relieve symptoms and prevent secondary bacterial infections. Monitor bites and prevent future bites. ◦ Apply ice pack (wrapped in a washcloth) to the affected area for up to 10 minutes with at least 10 minutes between applications ◦ Appropriate for fleas, mosquitoes, chiggers, or bedbugs (not scabies) ◦ If insufficient relief, apply external analgesic ◦ Avoid scratching the bite or wearing rough/irritating clothing over the bite area Exclusion Criteria for Insect Bites ◦ Hypersensitivity to insect bites, resulting in systematic symptoms or symptoms away from the insect bite ◦ < 2 years of age (external analgesics cannot be used) ◦ History of tick bite and systemic effects indicating infection present ◦ Would still remove tick, clean area with rubbing alcohol, and save tick for future identification if symptoms develop ◦ Suspected spider bite that would require medical attention ◦ Suspected scabies infection (no OTCs to treat) ◦ Secondary infection signs present Nonpharmacologic Prevention: Avoidance of Insects ◦ Cover skin as much as possible with clothing and socks, and cuff clothing around ankles, wrists, and neck ◦ Avoid swamps, dense woods, & dense brush harboring mosquitoes, ticks, and chiggers ◦ Keep pets free of pests (treat for prevention of ticks, fleas, etc) ◦ Remove standing water from around home to reduce breeding areas for mosquitoes ◦ Limit the amount of time spent outside at dawn and dusk ◦ Use barriers such as window screens and netting ◦ For bed bugs: Don't put your clothes on the carpets or on upholstered chairs. Keep your suitcase off the floor and the bed, use a metal suitcase rack if one is available ◦ Check out bed-bug registry: http://bedbugregistry.com/ Prevention: Insect Repellents N, N – diethyl – m – toluamide or DEET Other Insect Repellents ◦ Most effective all purpose repellent ◦ Alternative products include essential oils ◦ Does not kill insect, vapor repels them to such as citronella, oil of lemon eucalyptus protect against bites (10 – 35%) (OLE), soybean oil, lavender oil, tea tree oil, garlic, or scented moisturizers in ◦ 20%+ best for tick bit prevention mineral oil (ie: Skin-s—Soft) ◦ Applied every 4 – 8 hours, not more ◦ Less effective than DEET, especially with mosquitos and duration of action ◦ Various concentrations, children below ◦ OLE similar protection as DEET for malaria 30% and not on infants < 2 months prevention, effect not as long ◦ Safe in pregnancy & lactation ◦ Picaridin is promoted as less odorous and ◦ 50%+ no greater benefit but may last irritating than DEET longer, increased risk of skin reactions, especially if occluded ◦ IR3535 7.5%, likely similar efficacy to picaridin ◦ Rare CNS reactions, not to be combined with sunscreens due to frequent ◦ Permethrin 0.5% is designed for clothing application and camping equipment Selected Insect Repellants (Table1) Trade Name Primary Ingredients Cutter Skinsations Insect Repellent Pump Spray DEET 7%; aloe vera; vitamin E Cutter Sport Insect Repellent DEET 15% OFF! Deep Woods Sportsmen Insect Repellent I Pump DEET 98.25% Spray OFF! EXPLORE Insect Repellent I DEET 25% OFF! FamilyCare Pump DEET 7% OFF! Deep Woods Insect Repellent Towelettes DEET 25% Skin So Soft Bug Guard Plus IR3535 Gentle Breeze SPF 30 IR3535 7.5%; SPF 30 Lotion sunscreen Skin So Soft Bug Guard Plus Picaridin Aerosol Spray Picaridin 10% Repel Plant-Based Lemon Eucalyptus Insect Repellent Lemon eucalyptus oil 30% Pump Spray EPA Guidelines for Safe Use DEET (Table 2) ◦ Read and follow all directions and ◦ Avoid over application of this product. precautions on the product label. ◦ After returning indoors, wash treated skin ◦ Do not apply product over cuts, wounds, with soap and water. or irritated skin. ◦ Wash treated clothing before wearing it ◦ Do not apply product to hands or near again. eyes and mouth of young children. ◦ Product may damage synthetic fibers ◦ Do not allow young children to apply this and plastics. product. ◦ Use of this product may cause skin ◦ Use just enough repellent to cover reactions in rare cases. exposed skin and/or clothing. ◦ Do not spray product in enclosed areas. ◦ Apply the sunscreen first, followed by the ◦ To apply to face, spray product on hands repellent, when sunscreen needs to be first, and then rub on face. used in conjunction with a repellent. ◦ Do not use product under clothing. ◦ Do not spray product directly onto face. Pharmacological Therapy: External Analgesics* ◦ Topical Antihistamines ◦ Diphenhydramine HCl ◦ Local Anesthetics ◦ May apply up to 3 – 4 times per day ◦ Benzocaine, pramoxine, lidocaine, dibucaine, phenol, and benzyl ◦ Depress cutaneous receptors, help pain alcohol and itching ◦ Relief of itching and irritation ◦ May apply up to 3 – 4 times per day ◦ Counterirritants ◦ Be aware of allergic reactions (like ◦ Camphor & menthol w/ hemorrhoids) ◦ May apply up to 3 – 4 times per day ◦ Do not occlude phenol (0.5 – 1.5%) ◦ Relieve itching and irritation, “cooling” or apply extensively to body ◦ Hydrocortisone 1% * Not approved children < 2 years old ◦ May apply up to 3 – 4 times per day ◦ Not for scabies or infections Pharmacologic Therapy: continued ◦ Skin protectants ◦ Seek medical attention if the ◦ May be used to reduce condition worsens during irritation or inflammation, and treatment or if symptoms can absorb weeping fluids persist for 7 days ◦ Calamine or zinc oxide ◦ Local anesthetics, ◦ May be used on children < 2 counterirritants, topical years old antihistamines, and ◦ As needed up to 4 times per hydrocortisone should not be day used for > 7 days ◦ Some products combine Insect Stings Honeybees, wasps, hornets, and yellow jackets Honeybee stinger is barbed, will continue to inject venom HB may cause a greater release of histamine compared with Others are not barbed, insects may sting again Fire Ants South, some just bite, others bite and sting Intense itching, burning, vesiculation, or tissue necrosis Fire Ants in Texas Treatment Goals & General Approach ◦ Goal is to relieve itching and pain, allergic reactions require medical referral, and prevent future stings ◦ Removal of a stinger followed by application of ice in 10 minute intervals to slow absorption and help with pain/swelling ◦ Removal of honey bee stinger and sac should be done quickly (2 – 3 minutes) to empty contents ◦ Do not squeeze sac/stinger, scrap away with fingernail or credit card ◦ Apply antiseptic (alcohol or hydrogen peroxide) after removed Exclusion Criteria for Insect Stings ◦ Hives, excessive swelling, dizziness, weakness, nausea, vomiting, difficulty breathing ◦ Significant allergic response away from site of sting ◦ Previous sting by honeybee, wasp, or hornet (need to evaluate possible development of hypersensitivity) – can still treat ◦ Previous severe reaction to insect bites ◦ Personal or family history of significant allergic reactions ◦ < 2 years of age (external analgesics cannot be used) Nonpharmacologic Prevention: Avoidance of Insects ◦ To avoid attracting stinging insects: ◦ Avoid wearing perfume, scented lotions, or brightly colored clothes; ◦ Control odors in picnic and garbage areas; ◦ Change children’s clothing if it becomes contaminated with summer foods such as fruits; ◦ Wear shoes when outdoors; and ◦ Destroy nests of stinging insects near homes ◦ If hypersensitive to stings, wear a bracelet or carry a card showing the nature of the allergy Pharmacological Therapy: External Analgesics ◦ Same as bites: ◦ Local anesthetics ◦ Topical antihistamines ◦ Counterirritants ◦ Hydrocortisone ◦ FDA labeling is for “insect bites”, generally accepted they should be used for up to 7 days ◦ Complementary: ammonia and baking soda Pediculosis ◦ Three common types: ◦ P. humanus capitas ◦ P. humanus corporis ◦ Phthirus pubis Life Cycle of Head Lice ◦ Commonly spread with head-to-head contact ◦ Usually peak in August to November in schools ◦ Impacts all socioeconomic groups ◦ Louse requires a blood meal within 24 hours of hatching ◦ Bite creates a wheal and papule, subsequent itching ◦ Size of sesame seed ◦ Female lives one month and lays 7-10 nits/day which hatch in 8-10 days, becomes mature adult in 8-9 days ◦ Nits/nit castings found cemented to the hair shaft Assessment ◦ Head Lice - Direct examination ◦ Complete with gloves, light, and hand magnifier ◦ Few adult lice are generally found ◦ Nits found up the hair shaft, at the nape of the neck or behind the ears ◦ Body Lice ◦ Adult lice and nits in seams of clothing Treatment Goals & General Approach ◦ Treatment goals are to rid the infestation from the patient ◦ Killing lice and nits, removing nits ◦ Apply pediculicide to the infected area, remove nits and dead lice with hair comb ◦ Use FDA approved nit comb ◦ Avoid future infestations ◦ Nonprescription pediculicide resistance LiceMeisterTM Comb has been a problem ◦ 2016 study found resistance in 42 states Exclusion Criteria ◦ Hypersensitivity to chrysanthemums, ragweed, or pediculicide ingredients ◦ Cannot use OTC FDA approved products (though, new option available) ◦ Presence of secondary skin infection ◦ < 2 years old for pyrethrins ◦ < 2 months old for permethrins ◦ Lice infestation of eyelids or eyebrows ◦ Pregnancy or breast – feeding ◦ Strong caution on self-treatment, benefit vs. risk ◦ Regional resistance to pediculicides ◦ Presence of active tumors (pyrethrins) Nonpharmacologic Therapy ◦ AirAlle ◦ Applies heat to head and scalp to kill lice and nits, FDA approved ◦ Certified technician, kills > 90% of nits, expensive ◦ Avoidance of direct physical contact ◦ Do not share combs, brushes, towels, hats ◦ Wash clothing and bedding in hot water and clothes dryer ◦ Hair brushes and combs washed in very hot water ◦ If cannot be washed, seal in a plastic bag for 2 weeks ◦ Carpets, rugs, furniture should be vacuumed regularly ◦ Sprays are not generally recommended, louse will die < 48 hours without a blood meal Synergized Pyrethrins ◦ Approved for head and pubic lice ◦ Synergized with addition of piperonyl butoxide, limiting ability of lice to break down pyrethrin, resulting in higher/more toxic concentrations (0.17 – 0.33% with 2 – 4% piperonyl butoxide) ◦ Allows increased levels insecticide levels to louse ◦ Blocks nerve impulse transition killing louse, not eggs ◦ Low toxicity if used as directed, adverse reactions may include irritations, redness, swelling, or itching ◦ Do not use if allergic to pyrethrins, chrysanthemums, rag-weed allergies cross-sensitivity Permethrin ◦ 1% Cream rinse for head lice only ◦ Disrupts nerve cell membrane of lice (sodium channel) killing the louse, but again not the eggs ◦ 10% of patients report adverse effects including itching, burning, stinging, and irritation ◦ Contraindicated in patients with sensitivity to pyrethrins, chrysanthemums ◦ In single application comparison, permethrin is more effective than pyrethrin (no data in comparison of 2 applications) OTC Product Directions Synergized Pyrethrins Permethrin ◦ Applied as a shampoo, foam, solution, ◦ Applied to washed towel dry hair or gel (apply foam to dry hair) ◦ Saturate hair and scalp, leave on hair ◦ Applied to affected area for 10 for 10 minutes then rinse minutes then rinsed or shampooed ◦ Must comb with lice comb following (foam washed out) treatment ◦ Must comb with lice comb following ◦ Cream rinse has residual effects for up treatment to 10 days, retreatment is not necessary ◦ May repeat in 7 – 10 days to kill 7 – 10 days later unless new lice remaining nits that may have hatched detected ◦ Do not apply > 2 times in 24 hours ◦ Avoid contact with eyes ◦ Avoid contact with eyes Ivermectin (Sklice®) ◦ www.sklice.com Ivermectin 0.5% (Sklice®) Key Points Instructions for Use ◦ MOA: Targets nerve cell membrane ◦ Age 6 months+ through selective glutamate-gated ◦ Apply to dry hair chloride channels ◦ Resulting in paralysis and death ◦ Start at the scalp and work your way to ◦ Also toxic to eggs/nits the back areas of the head ◦ Lice nit combing is not necessary, but ◦ Thoroughly coat the scalp and hair may want to do for cosmetic reasons ◦ Wait 10 minutes as soon as done with ◦ > 70% were lice free at 14 days in 2 application randomized, double-blind trials ◦ Rinse hair to remove lotion, discard ◦ Will no longer be available Rx, OTC only excess lotion, do not shampoo 24 hours Homeopathic: Natrum muriaticum ◦ Sodium chloride solution (2X HPUS) which dehydrate lice & eggs ◦ Pediatric based, open-label, randomized controlled trial with 42 patients, homeopathic solution showed greater efficacy compared to permethrin ◦ Efficacy observed on days 1-8 and 15 ◦ 85% higher pediculicide activity with 1% NaCl compared with 1% permethrin (45%) at day 15 ◦ Apply to dry hair (saturate hair) and comb with nit comb Serrano L, Decesar L, Pham L. Evaluation of the efficacy and safety of sodium chloride (LiceFreee Spray) against 1% permethrin crème rinse on head lice infested individuals. Pharmacology & Pharmacy. 2013:4(2);266–73. doi: 10.4236/pp.2013.42038. Alternative Therapies ◦ Not FDA Approved ◦ Lice enzyme shampoos to break down exoskeleton ◦ 10% tea tree oil and 1% lavender oil applied weekly for 3 weeks ◦ One study showed more effective than 2 applications pyrethrin/pb ◦ Petroleum jelly, mayonnaise, or olive oil – not effective ◦ Battery operated combs ◦ Claim to kill lice, no evidence published ◦ Avoid in patients with pacemakers of history of seizures Emerging Therapies ◦ Dry-on, Suffocation Pediculicide (DSP) lotions ◦ Nuvo method ◦ Cetaphil Gentle Skin Cleanser ◦ Applied to hair and dried with hair dryer ◦ Shrink wraps lice by suffocation ◦ http://nuvoforheadlice.com/?page_id=9 ◦ Dimethicone 100% gel (Lice MD) ◦ Effective with less irritation ◦ Coats lice and irreversibly immobilizes them within 5 minutes Selected Products Trade Name Primary Ingredients A-200 Lice Killing Shampoo Pyrethrins 0.33%; piperonyl butoxide 3% RID Lice Killing Shampoo, Pyrethrins 0.33%; piperonyl butoxide 4% Maximum Strength Nix Lice Killing Cream Rinse Permethrin 1% Pronto Lice Killing Shampoo Pyrethrins 0.33%; piperonyl butoxide 4% Sklice Ivermectin 0.5% LiceMD Dimethicone 100% Vamousse Lice Treatment Natrum muriaticum 2X (HPUS) Licefreee Spray Natrum muriaticum 2X (HPUS) Clearlice Shampoo Proprietary blend: enzyme proteins, neem oils, Wrightia tinctoria, tea tree oil, Acorus calamus, peppermint oil, Cocos nucifera, Natrum muriaticum Key Points ◦ Assess and confirm lice/nits are present ◦ May want to refer if there is regional resistance reported ◦ Alternatives are available for self-care ◦ Select appropriate treatment and counsel ◦ Re-evaluate around 10 days after treatment ◦ Nonpharmacologic measures are important in prevention and eradication of lice

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